Treatment

Treating glaucoma is very individualized and varies depending on the degree of damage present. Pressure lowering eye drops are the first line treatment for glaucoma. Most glaucoma patients require more than one drop to achieve adequate eye pressure. Not all drops work effectively for each patient. If eye pressure is inadequate with drops, a laser procedure can be performed in certain types of glaucoma to lower the eye pressure. In advanced glaucoma or in cases where the eye pressure is dangerously high, there are surgical procedures that can be performed in the operating room to lower the eye pressure. It is our job as your glaucoma providers to discuss appropriate treatment options, including risks and benefits, and determine the best treatment plan for you.

Types of Pressure Lowering Drops

There are currently 6 different types of eye drops most commonly used for the medical treatment of glaucoma.

Prostaglandin analogs (Latanoprost (Xalatan), Travoprost (Travatan, Travatan Z), Bimatoprost (Lumigan, Vyzulta)) (turquoise tops) are first-line therapy in the medical management of glaucoma, and are used once daily, usually at bedtime. They reduce intra-ocular pressure by enhancing the removal of fluid (aqueous humor) from the eye. In studies, prostaglandin analogs were able to reduce eye pressure by 30% to 35%; an additional drop in pressure is possible when these medicines are taken in combination with other medicines.

Beta-blockers (betaxolol, timolol, timoptic, betoptic, optipranolol, carteolol) (yellow or blue tops) are another common medication. They lower eye pressure by decreasing the amount of fluid made within your eye. They are either used once or twice daily. Complications associated with these medications are rare, but should be understood so that you do not take a medication that is not appropriate for you. They should not be used in the following patients: those who have asthma, severe heart failure, blockage of their carotid arteries, a slow pulse, severe lung or heart disease, or are prone to depression. Additionally, males with a history of sexual dysfunction may want to ask their doctors about the advisability of this class of medications. Some beta blockers, such as Betoptic, are less likely to cause negative side effects.

Alpha-agonists (Brimonidine, Alphagan-P) (purple tops) are used twice or three times daily. These drops lower eye pressure by decreasing the amount of aqueous humor produced.

Miotics (Pilocarpine) (green tops) are the oldest class of medications used for glaucoma. They work by increasing the amount of fluid which leaves the eye and are given at various dosing intervals varying between once weekly to four times daily. We have used this class of medication for over a century. These drops make your pupil smaller, which may affect your vision. Headaches are common when beginning this drop.

Rho Kinase inhibitors (Rhopressa) (white top) are a newer class of pressure lowering medications. They are dosed only once daily. This drug lowers eye pressure by suppressing rho kinase enzymes, which are responsible for fluid buildup. Through this mechanism they are able to increase the drainage of fluid and lower eye pressure.

The Importance of Taking Drops as Instructed

Drops only work when you take them. If you don't use your eye drop regularly, you are only hurting yourself. Every time you miss an eye drop, there is a time when your eye pressure may be rising again. If you are to take any eye drop three times daily, and you regularly miss one of the three drops, over the course of a year, you might be missing one third of the eye drops you need. This is equivalent to missing eye drops for four months every year!

Eye drops can be difficult to instill. It is okay to have a friend or family member help you instill an eye drop. It does not matter which part of the eye that the drop touches, as long as it gets onto the eye (being on the eye lid is NOT enough)! Be careful not to touch the bottle tip to your eye. People often worry about how many eye drops they should put into their eyes. All you need is one. It is normal for some part of an eye drop to roll down your cheek.

Most glaucoma patients require more than one drop to successfully lower their pressure. You should wait at least 5 minutes between each drop to ensure that you do not wash out the first drop when you instill the second drop.

Laser Treatments for Glaucoma

Lasers were first introduced in the therapy of glaucoma in the 1970s. The types of lasers performed for glaucoma are laser peripheral iridotomy and laser trabeculoplasty (ALT or SLT). Peripheral iridotomy is performed for narrow or closed angle glaucoma, and trabeculoplasty is performed in cases of open angle glaucoma.

Laser procedures are done in the office and are quite safe. It only takes a few minutes to perform the laser, but you should plan to be in our office for ~2 hours, so that we may check the pressures before and after the laser. You may feel a “pin-prick” sensation during the laser but should not experience any pain. Your vision might be slightly blurry for about an hour. Your eye might feel scratchy, irritated, or red for 1-2 days.

Trabeculoplasty laser procedures do not take full effect for about four to six weeks. The laser works adequately to lower the eye pressure in approximately 80% of people one year later. At five years, it is ~50%.

The laser has proven to be safe and effective. It is often performed in cases of early glaucoma as opposed to adding an additional drop.

Unfortunately, for patients with advanced glaucoma, or certain types of glaucoma, laser treatment may not recommended.

LASIK laser is NOT a treatment for glaucoma, is not related to glaucoma., and is NOT performed by our doctors. LASIK will not improve vision that has been compromised due to glaucoma.

Surgery for Glaucoma

Glaucoma surgery is performed in the operating room and is outpatient. Dr. Robin performs two different types of glaucoma surgeries: trabeculectomy and insertion of a glaucoma drainage device. For both procedures, an anesthesiologist provides “twilight” anesthesia. Local anesthesia is also provided to ensure you are comfortable and fully numb.

Trabeculectomy

Trabeculectomy is the gold standard surgical treatment for glaucoma. It takes ~25-30 minutes. It involves making an incision underneath the upper eyelid in the wall (sclera) of the eye to create a place for fluid to flow. In glaucoma, the drain of the eye is compromised and cannot properly filter the fluid inside the eye, so it becomes trapped. This surgery creates a place for the fluid to escape, thus reducing the pressure. A trabeculectomy is performed using only your own anatomy. No devices or stents are inserted in the eye. Approximately 85% of the time, surgery is successful and patients do not need to use any drops 3 months after the surgery because the surgical site is enough to lower the pressure alone.

Insertion of a glaucoma drainage device

In cases where a trabeculectomy has failed or in certain types of glaucoma, a drainage device can be inserted into the eye. This device is a small tube that is not visible to the naked eye and only seen under magnification in office. It does NOT contain any metal. This surgery is more surgically challenging, and takes ~30-40 minutes. Patients may still require a glaucoma drop following the procedure to adequately lower the pressure.

Following both types of procedures, you will wear a patch over your eye until the following day. Your vision may be blurry for up to a month. Pain after surgery is rare, but discomfort, irritation, and soreness are possible. Restrictions after surgery include no eye rubbing indefinitely, no bending over for long periods of time (yoga, gardening) for 10 days, no lifting over 25 lbs for 10 days, and no contact lens wear.

As with any surgery, benefits must outweigh the risks. If surgery is appropriate for you, your doctor will go into great detail about the surgical process, discuss all risks and benefits with you, and answer any questions.

The goal of any glaucoma surgery is to keep the disease stable. Glaucoma surgery cannot improve vision or bring back any vision that has been lost. It can, however, lower the pressure to prevent further vision loss.

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